Basic Information
Provider Information | |||||||||
NPI: | 1477504595 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POWELL | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OSBORNE | ||||||||
OtherFirstName: | KELLY | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1221 S BROADWAY | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405042701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592586200 | ||||||||
FaxNumber: | 8592586203 | ||||||||
Practice Location | |||||||||
Address1: | 3085 LAKECREST CIR | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405131707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592588600 | ||||||||
FaxNumber: | 8592588610 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2006 | ||||||||
LastUpdateDate: | 03/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA942 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.